Would you rather receive $100 today or wait for a year and then receive $150? The ability to delay immediate gratification for a potentially greater payout in the future is associated with greater wealth. Several studies have shown that the poor tend to opt for immediate rewards even if they are lower, whereas the wealthy are willing to wait for greater rewards. One obvious reason for this difference is the immediate need for money. If food has to be purchased and electricity or water bills have to be paid, then the instant “reward” is a matter of necessity. Wealthier people can easily delay the reward because their basic needs for food, shelter and clothing are already met.

Unfortunately, escaping from poverty often requires the ability to delay gratification for a greater payout in the future. Classic examples are the pursuit of higher education and the acquisition of specialized professional skills which can lead to better-paying jobs in the future. Attending vocational school, trade school or college paves the way for higher future wages, but one has to forego income during the educational period and even incur additional debt by taking out educational loans. Another example is of delayed gratification is to invest capital – whether it is purchasing a farming tool that increases productivity or investing in the stock market – which in turn can yield greater pay-out. However, if the poor are unable to pursue more education or make other investments that will increase their income, they remain stuck in a vicious cycle of increasing poverty.

Understanding the precise reasons for why people living in poverty often make decisions that seem short-sighted, such as foregoing more education or taking on high-interest short-term loans, is the first step to help them escape poverty. The obvious common-sense fix is to ensure that the basic needs of all citizens – food, shelter, clothing, health and personal safety – are met, so that they no longer have to use all new funds for survival. This is obviously easier in the developed world, but it is not a trivial matter considering that the USA – supposedly the richest country in the world – has an alarmingly high poverty rate. It is estimated that more than 40 million people in the US live in poverty, fearing hunger and eviction from their homes. But just taking care of these basic needs may not be enough to help citizens escape poverty. A recent research study by Jon Jachimowicz at Columbia University and his colleagues investigated “myopic” (short-sighted) decision-making of people with lower income and identified an important new factor: community trust.

The researchers first used an online questionnaire (647 participants) to assess trust and asked participants to choose between a payoff in the near future that is smaller and a larger pay-off in the distant future. They also measured community trust by asking participants to agree or disagree with statements such as “There are advantages to living in my neighborhood” or I would like my child(ren) to be raised in the neighborhood I currently live in”. They found that lower income participants were more likely to act in a short-sighted manner if they had low levels of trust in their communities. In a second online experiment, the researchers recruited roughly 100 participants from each state in the US and assessed their community trust levels. They then obtained real-world data on payday loans – a sign of very short-sighted financial decision-making because people take out cash advances at extraordinarily high interest rates that have to be paid back when they get their paycheck – for each state. They found that the average community trust for each state was related to the use of payday loans. In states with high average community trust ratings, people were less likely to take out these payday loans, and this trend remained even when the researchers took into account unemployment rates and savings rates for each state.

Even though these findings all pointed to a clear relationship between community trust and sound financial decision-making, the results did not prove that increased community trust is an underlying cause that helps improve the soundness of financial decisions. To test this relationship in a real-world setting, the researchers conducted a study in rural Bangladesh by collaborating with an international development organization based in Bangladesh. The vast majority of participants in this study were poor even by Bangladeshi standards, earning less than $1/day per household member. The researchers adapted the community trust questionnaire and the assessment of financial decision-making for the rural population, with live interviewers asking the questions and filling out the responses for the participants. After assessing community trust and the willingness to delay financial rewards for greater payouts in the future, half of the participants received a two year intervention to increase community trust. This intervention involved volunteers from the community that acted as intermediaries between the local government and the rural population, providing input into local governance and community-level decisions (for example in the distribution of social benefits and the allocation of funds for development projects).

At the end of the two year period, participants who had received the community intervention showed significant increases in their community trust levels and they also improved their financial decision-making. They were more likely to forego immediate lower financial rewards for greater future rewards when compared to the villagers who did not receive any special intervention.

By combining correlational data from the United States with an actual real-world intervention to build community trust, the researchers show how important it is to build trust when we want to help fellow humans escape the “poverty trap“. This is just an initial study with a limited group of participants and a narrow intervention that needs to be replicated in other societies and with long-term observation of the results to see how persistent the effects are. But the results should make all of us realize that just creating “jobs, jobs, jobs” is not enough. We need to invest in the infrastructures of communities and help citizens realize that they are respected members of society with a voice. Empowering individuals and ensuring their safety, dignity and human rights are necessary steps if we are serious about battling poverty.

What is the externalization society? According to Lessenich, this expression describes how developed countries such as the United States, Japan and Germany transfer or externalize risks and burdens to developing countries in South America, Africa and Asia. The Bento Rodrigues disaster is an example of the environmental risk that is externalized. Extracting metals that are predominantly used by technology-hungry consumers in developed countries invariably generates toxic waste which poses a great risk for the indigenous population of many developing countries. The externalized environmental risks are not limited to those associated with mining raw materials. The developed world is also increasingly exporting its trash into the third world.

The US, for example, are the world’s largest exporter of paper trash, exporting scrap paper worth US$ 3.1 billion each year. The US is also the largest producer of electronic waste (E-Waste), estimated at more than 7 million tons of E-Waste per year (PDF). Every new smartphone or tablet release generates mountains of E-Waste as consumers discard their older devices. Re-cycling the older devices sounds like a reasonable solution bu true recycling and re-using of electronic components is quite costly and time-consuming. It is also often not clear which electronic components of devices actually get recycled. To track the fate of discarded electronic devices, Jim Puckett from the Basel Action Network and his colleagues placed GPS-trackers in old electronics dropped off at US-based recycling centers. They found that a third of the “recycled” electronics were shipped overseas to countries such as Mexico, Taiwan, China, Pakistan, Thailand and Kenya. Puckett used the GPS signal to identify the sites where the E-Waste ended up and visited such a location in Hong Kong, where he found that the “recycled” electronics were being dismantled in junkyards by migrant workers from mainland China who were not wearing any protective clothing that would have protected them from hazardous materials released during the extraction of salvageable E-Waste materials. There are many regulations that restrict the trading of E-Waste but the United Nations Environment Program (UNEP) estimates that up to 90% of the world’s E-Waste is traded or dumped illegally. This means that even though dropping off old devices at a recycling center may alleviate the conscience of consumers, a significant number of these will not be re-used but instead shipped off to junkyards in other countries – without appropriate monitoring of how these electronic waste products will affect the local environment and health of the population.

Exporting environmental risks to developing countries by either outsourcing high-risk extraction of raw materials or simply dumping waste is just one example of externalization according the Lessenich. Externalizing occupational health risks and poverty by severely under-paying workers are other examples. Bangladesh has now emerged as one of the world’s largest manufacturers of clothing because of its cheap labor. In 2011, the typical monthly wage of a garment industry worker in Bangladesh was estimated at $91 per month – roughly one and a half dollars per day! In addition to this dismally low pay, garment factory workers in Bangladesh also face terrible occupational risks. The collapse of the Rana Plaza garment factory building in 2013 which called over 1,100 people and injured more than 2,500 people is just one example of the occupational risks faced by the workers.

Lessenich’s concept of the externalization society isn’t just another critique of the global inequality that we so often hear about. The fundamental principle of the externalization society put forth by Lessenich is the interdependence between the “imperial lifestyle” of wealth and comfort in the developed world and the “wretched lifestyle” of poverty and hardship in the developing world. If those of us who live in the developed world want the convenience of upgrading our smartphones every few years or buying cheap cotton t-shirts, then we need those who manufacture these products in the developing world to be paid lousy wages. If those workers were paid humane wages and their employers instituted appropriate occupational safety measures, as well as health and disability insurance plans that are routine in most parts of the developed world, then the cost of the products would be incompatible with our current economy and lifestyle which are fueled by consumerism and the capitalist imperative of incessant growth.

The pillars of the externalization society are indifference and ignorance. We are indifferent because we see the differential in lifestyle as a Selbstverständlichkeit – a German word for obviousness or taken-for-grantedness. They were born in developing countries, so of course they have to struggle – tough luck, they ended up with the wrong lottery tickets. This Selbstverständlichkeit also extends to the limited mobility of the people born in the developing world. They lack the birthright of the developing world citizens whose passports allow them to either travel visa-free or obtain a visa to nearly any country in the world with minimal effort. This veneer of Selbstverständlichkeit is easiest to maintain if “they” and “their” problems are invisible and thus allow us to ignore the interdependence between our good fortune and their misery. We might see images of the toxic flood in Brazil but few, if any, members of the externalization society will link the mining of cheap iron in Brazil to the utensils they use in their everyday life.

A decade ago, disposable single-use coffee pods such as the Keurig K-cups or the Nespresso pods were extremely rare but by 2014, K-cup manufactures sold a mind-boggling 9 billion K-cups! A new need for disposable products that had previously been met by standard coffee machines arose without considering the environmental and global impact of this need. In theory, the K-cups are recyclable but this would require careful separating of the paper, plastic and the aluminum top. It is not clear how many K-cups are properly recycled, and the E-Waste example shows that even if items are transported to recycling centers, that does not necessarily mean that they will be successfully recycled. Prior to the advent coffee pods, our coffee demands had been easily met without generating additional mountains of disposable plastic and aluminum coffee pod trash. Out of nowhere, there arose a new need for aluminum which again is extracted from the aluminum ore bauxite – another process that generates toxic waste. Instead of feeling a sense of absolution when we drop a disposable item into a recycling bin, we should simply curtail unnecessary consumption of products in disposable containers.

How do we overcome the externalization society? We can make concerted efforts through advocacy, education and regulations that restrict exporting environmental waste, improve health and safety conditions for workers in the developing world and try to restrict our consumerist excesses by clarifying the interdependence between wealth in the externalization society and the poverty in the developing world as well as the moral imperative to abrogate the inequality and asymmetry. Numerous advocates have already attempted this approach for the past decades with limited success. Maybe instead of appealing to the ethics of interdependence, a more effective approach may be to educate each other about the consequences of the interdependence. When millions of refugees show up at the doorstep of the externalization society, “they” are no longer invisible. One can blame wars, religious extremism and political ideologies for the misery of the refugees but it becomes harder to ignore the extent and central role of the underlying inequality. Creating humane working and living conditions for people in the developing world is perhaps the most effective way to stop the so-called “refugee crisis“.

Global climate change is another threat to the externalization society, a threat of its own making. Transferring carbon footprints and pollution to other countries does not change the fact that the whole planet is suffering from the consequences of climate change. Political leaders of the externalization society often demand the closing of borders, erecting walls and expanding their armed forces so they are less likely to have to confront the victims of their externalization but no army or wall is strong enough to lower the rising water levels or stabilize the climate. The externalization society will end not because of a crisis of conscience but because its excesses are undermining its own existence.

“It’s empathy that makes us help other people. It’s empathy that makes us moral.” The economist Paul Zak casually makes this comment in his widely watched TED talk about the hormone oxytocin, which he dubs the “moral molecule”. Zak quotes a number of behavioral studies to support his claim that oxytocin increases empathy and trust, which in turn increases moral behavior. If all humans regularly inhaled a few puffs of oxytocin through a nasal spray, we could become more compassionate and caring. It sounds too good to be true. And recent research now suggests that this overly simplistic view of oxytocin, empathy and morality is indeed too good to be true.

Many scientific studies support the idea that oxytocin is a major biological mechanism underlying the emotions of empathy and the formation of bonds between humans. However, inferring that these oxytocin effects in turn make us more moral is a much more controversial statement. In 2011, the researcher Carsten De Dreu and his colleagues at the University of Amsterdam in the Netherlands published the study Oxytocin promotes human ethnocentrism which studied indigenous Dutch male study subjects who in a blinded fashion self-administered either nasal oxytocin or a placebo spray. The subjects then answered questions and performed word association tasks after seeing photographic images of Dutch males (the “in-group”) or images of Arabs and Germans, the “out-group” because prior surveys had shown that the Dutch public has negative views of both Arabs/Muslims and Germans. To ensure that the subjects understood the distinct ethnic backgrounds of the target people shown in the images, they were referred to typical Dutch male names, German names (such as Markus and Helmut) or Arab names (such as Ahmed and Youssef).

Oxytocin increased favorable views and word associations but only towards in-group images of fellow Dutch males. The oxytocin treatment even had the unexpected effect of worsening the views regarding Arabs and Germans but this latter effect was not quite statistically significant. Far from being a “moral molecule”, oxytocin may actually increase ethnic bias in society because it selectively enhances certain emotional bonds. In a subsequent study, De Dreu then addressed another aspect of the purported link between oxytocin and morality by testing the honesty of subjects. The study Oxytocin promotes group-serving dishonesty showed that oxytocin increased cheating in study subjects if they were under the impression that dishonesty would benefit their group. De Dreu concluded that oxytocin does make us less selfish and care more about the interest of the group we belong to.

These recent oxytocin studies not only question the “moral molecule” status of oxytocin but raise the even broader question of whether more empathy necessarily leads to increased moral behavior, independent of whether or not it is related to oxytocin. The researchers Jean Decety and Jason Cowell at the University of Chicago recently analyzed the scientific literature on the link between empathy and morality in their commentary Friends or Foes: Is Empathy Necessary for Moral Behavior?, and find that the relationship is far more complicated than one would surmise. Judges, police officers and doctors who exhibit great empathy by sharing in the emotional upheaval experienced by the oppressed, persecuted and severely ill always end up making the right moral choices – in Hollywood movies. But empathy in the real world is a multi-faceted phenomenon and we use this term loosely, as Decety and Cowell point out, without clarifying which aspect of empathy we are referring to.

Decety and Cowell distinguish at least three distinct aspects of empathy:

1. Emotional sharing, which refers to how one’s emotions respond to the emotions of those around us. Empathy enables us to “feel” the pain of others and this phenomenon of emotional sharing is also commonly observed in non-human animals such as birds or mice.

2. Empathic concern, which describes how we care for the welfare of others. Whereas emotional sharing refers to how we experience the emotions of others, empathic concern motivates us to take actions that will improve their welfare. As with emotional sharing, empathic concern is not only present in humans but also conserved among many non-human species and likely constitutes a major evolutionary advantage.

3. Perspective taking, which – according to Decety and Cowell – is the ability to put oneself into the mind of another and thus imagine what they might be thinking or feeling. This is a more cognitive dimension of empathy and essential for our ability to interact with fellow human beings. Even if we cannot experience the pain of others, we may still be able to understand or envision how they might be feeling. One of the key features of psychopaths is their inability to experience the emotions of others. However, this does not necessarily mean that psychopaths are unable to cognitively imagine what others are thinking. Instead of labeling psychopaths as having no empathy, it is probably more appropriate to specifically characterize them as having a reduced capacity to share in the emotions while maintaining an intact capacity for perspective-taking.

In addition to the complexity of what we call “empathy”, we need to also understand that empathy is usually directed towards specific individuals and groups. De Dreu’s studies demonstrated that oxytocin can make us more pro-social as long as it benefits those who we feel belong to our group but not necessarily those outside of our group. The study Do you feel my pain? Racial group membership modulates empathic neural responses by Xu and colleagues at Peking University used fMRI brain imaging in Chinese and Caucasian study subjects and measured their neural responses to watching painful images. The study subjects were shown images of either a Chinese or a Caucasian face. In the control condition, the depicted image showed a face being poked with a cotton swab. In the pain condition, study subjects were shown a face of a person being poked with a needle attached to syringe. When the researchers measured the neural responses with the fMRI, they found significant activation in the anterior cingulate cortex (ACC) which is part of the neural pain circuit, both for pain we experience ourselves but also for empathic pain we experience when we see others in pain. The key finding in Xu’s study was that ACC activation in response to seeing the painful image was much more profound when the study subject and the person shown in the painful image belonged to the same race.

As we realize that the neural circuits and hormones which form the biological basis of our empathy responses are so easily swayed by group membership then it becomes apparent why increased empathy does not necessarily result in behavior consistent with moral principles. In his essay “Against Empathy“, the psychologist Paul Bloom also opposes the view that empathy should form the basis of morality and that we should unquestioningly elevate empathy to virtue for all:

“But we know that a high level of empathy does not make one a good person and that a low level does not make one a bad person. Being a good person likely is more related to distanced feelings of compassion and kindness, along with intelligence, self-control, and a sense of justice. Being a bad person has more to do with a lack of regard for others and an inability to control one’s appetites.”

I do not think that we can dismiss empathy as a factor in our moral decision-making. Bloom makes a good case for distanced compassion and kindness that does not arise from the more visceral emotion of empathy. But when we see fellow humans and animals in pain, then our initial biological responses are guided by empathy and anger, not the more abstract concept of distanced compassion. What we need is a better scientific and philosophical understanding of what empathy is. Empathic perspective-taking may be a far more robust and reliable guide for moral decision-making than empathic emotions. Current scientific studies on empathy often measure it as an aggregate measure without teasing out the various components of empathy. They also tend to underestimate that the relative contributions of the empathy components (emotion, concern, perspective-taking) can vary widely among cultures and age groups. We need to replace overly simplistic notions such as oxytocin = moral molecule or empathy = good with a more refined view of the complex morality-empathy relationship guided by rigorous science and philosophy.

Anti-Semitism and the holocaust are among the central themes in the modern German secondary school curriculum. During history lessons in middle school, we learned about anti-Semitism and the persecution of Jews in Europe during the middle ages and early modernity. Our history curriculum in the ninth and tenth grades focused on the virulent growth of anti-Semitism in 20th century Europe, how Hitler and the Nazi party used anti-Semitism as a means to rally support and gain power, and how the Nazi apparatus implemented the systematic genocide of millions of Jews.

Image of a Hitler Youth meeting from the German Federal Archive via Wikimedia

In grades 11 to 13, the educational focus shifts to a discussion of the broader moral and political context of anti-Semitism and Nazism. How could the Nazis enlist the active and passive help of millions of “upstanding” citizens to participate in this devastating genocide? Were all Germans who did not actively resist the Nazis morally culpable or at least morally responsible for the Nazi horrors? Did Germans born after the Second World War inherit some degree of moral responsibility for the crimes committed by the Nazis? How can German society ever redeem itself after being party to the atrocities of the Nazis? Anti-Semitism and Nazism were also important topics in our German literature and art classes because the Nazis persecuted and murdered German Jewish intellectuals and artists, and because the shame and guilt experienced by Germans after 1945 featured so prominently in German art and literature.

One purpose of extensively educating Germany school-children about this dark and shameful period of German history is the hope that if they are ever faced with the reemergence of prejudice directed against Jews or any other ethnic or religious group, they will have the courage to stand up for those who are being persecuted and make the right moral choices. As such, it is part of the broader Vergangenheitsbewältigung (wrestling with one’s past) in post-war German society which takes place not only in schools but in various public venues. The good news, according to recent research published in the Proceedings of the National Academy of Sciences by Nico Voigtländer and Hans-Joachim Voth, is that Germans who attended school after the Second World War have shown a steady decline in anti-Semitism. The bad news: Vergangenheitsbewältigung is a bigger challenge for Germans who attended school under the Nazis because a significant proportion of them continue to exhibit high levels of anti-Semitic attitudes more than half a century after the defeat of Nazi Germany.

Voigtländer and Voth examined the results of the large General Social Survey for Germany (ALLBUS) in which several thousand Germans were asked about their values and beliefs. The survey took place in 1996 and 2006, and the researchers combined the results of both surveys with a total of 5,300 participants from 264 German towns and cities. The researchers were specifically interested in anti-Semitic attitudes and focused on three survey questions specifically related to anti-Semitism. Survey participants were asked to respond on a scale of 1 to 7 and indicate whether they thought Jews had too much influence in the world, whether Jews were responsible for their own persecution and whether Jews should have equal rights. The researchers categorized participants as “committed anti-Semites” if they revealed anti-Semitic attitudes to all three questions. The overall rate of committed anti-Semites was 4% in Germany but there was significant variation depending on the geographical region and the age of the participants.

Germans born in the 1970s and 1980s had only 2%-3% committed anti-Semites whereas the rate was nearly double for Germans born in the 1920s (6%). However, the researchers noted one exception: Germans born in the 1930s. Those citizens had the highest fraction of anti-Semites: 10%. The surveys were conducted in 1996 and 2006 when the participants born in in the 1930s were 60-75 years old. In other words, one out of ten Germans of that generation did not think that Jews deserved equal rights!

The researchers attributed this to the fact that people born in the 1930s were exposed to the full force of systematic Nazi indoctrination with anti-Semitic views which started as early as in elementary school and also took place during extracurricular activities such as the Hitler Youth programs. The Nazis came to power in 1933 and immediately began implementing a whole-scale propaganda program in all schools. A child born in 1932, for example, would have attended elementary school and middle school as well as Hitler Youth programs from age six onwards till the end of the war in 1945 and become inculcated with anti-Semitic propaganda.

The researchers also found that the large geographic variation in anti-Semitic prejudices today was in part due to the pre-Nazi history of anti-Semitism in any given town. The Nazis were not the only and not the first openly anti-Semitic political movement in Germany. There were German political parties with primarily anti-Jewish agendas which ran for election in the late 19th century and early 20th century. Voigtländer and Voth analyzed the votes that these anti-Semitic parties received more than a century ago, from 1890 to 1912. Towns and cities with the highest support for anti-Semitic parties in this pre-Nazi era are also the ones with the highest levels of anti-Semitic prejudice today. When children were exposed to anti-Semitic indoctrination in schools under the Nazis, the success of these hateful messages depended on how “fertile” the ground was. If the children were growing up in towns and cities where family members or public figures had supported anti-Jewish agenda during prior decades then there was a much greater likelihood that the children would internalize the Nazi propaganda. The researchers cite the memoir of the former Hitler Youth member Alfons Heck:

“We who were born into Nazism never had a chance unless our parents were brave enough to resist the tide and transmit their opposition to their children. There were few of those.”

The researchers then address the puzzling low levels of anti-Semitic prejudices among Germans born in the 1920s. If the theory of the researcher were correct that anti-Semitic prejudices persist today because Nazi school indoctrination then why aren’t Germans born in the 1920s more anti-Semitic? A child born in 1925 would have been exposed to Nazi propaganda throughout secondary school. Oddly enough, women born in the 1920s did show high levels of anti-Semitism when surveyed in 1996 and 2006 but men did not. Voigtländer and Voth solve this mystery by reviewing wartime fatality rates. The most zealous male Nazi supporters with strong anti-Semitic prejudices were more likely to volunteer for the Waffen-SS, the military wing of the Nazi party. Some SS divisions had an average age of 18 and these SS-divisions had some of the highest fatality rates. This means that German men born in the 1920s weren’t somehow immune to Nazi propaganda. Instead, most of them perished because they bought into it and this is why we now see lower levels of anti-Semitism than expected in Germans born during that decade.

A major limitation of this study is its correlational nature and the lack of data on individual exposure to Nazism. The researchers base their conclusions on birth years and historical votes for anti-Semitic parties of towns but did not track how much individuals were exposed to anti-Semitic propaganda in their schools or their families. Such a correlational study cannot establish a cause-effect relationship between propaganda and the persistence of prejudice today. One factor not considered by the researchers, for example, is that Germans born in the 1930s are also among those who grew up as children in post-war Germany, often under conditions of extreme poverty and even starvation.

Even without being able to establish a clear cause-effect relationship, the findings of the study raise important questions about the long-term effects of racial propaganda. It appears that a decade of indoctrination may give rise to a lifetime of hatred. Our world continues to be plagued by prejudice against fellow humans based on their race or ethnicity, religion, political views, gender or sexual orientation. Children today are not subject to the systematic indoctrination implemented by the Nazis but they are probably still exposed to more subtle forms of prejudice and we do not know much about its long-term effects. We need to recognize the important role of public education in shaping the moral character of individuals and ensure that our schools help our children become critical thinkers with intact moral reasoning, citizens who can resist indoctrination and prejudice.

About five million people in the US suffer from heart failure, and approximately half of them die within five years of being diagnosed. Only about 2,500 people a year receive a heart transplant – the treatment of last resort. A new heart can be life-saving, but it is also life-changing. Even under the best conditions, the surgery is complex, and recovery carries a heavy physical and emotional burden.

And not all heart transplant recipients fare equally well after the surgery. Researchers have found that black heart transplant patients are more likely to die after surgery than white or Hispanic patients.

While many different factors contribute to the disparity, the research indicates that where patients received their heart transplants played a big role. Black patients were more likely to have their transplants performed at the worst-performing centers.

This is merely one of many examples of health disparities faced by black Americans. But as a cardiologist, I find this finding especially troubling because many of the heart failure patients I treat are black.

So how do patients decide where to have their heart transplants performed? And wouldn’t a person who needs a heart transplant choose to go to a top center?

Quality is obviously a major factor. But there is another big consideration in deciding where to get a transplant: accessibility.

Not all transplant centers have the same results

Researchers at Ohio State University reviewed the records of heart transplants performed at 102 transplant centers in the US from 2000 to 2010. The researchers focused on the rate of death during the first year after the transplant in over 18,000 heart transplant recipients.

They found that black patients had a higher rate of dying within one year of receiving a new heart (15.3%) than either Hispanics (12.5%) or whites (12.8%).

To find out why this was happening, the researchers used a mathematical model to predict the risk of dying within a year after the transplant for every patient based on the severity of their disease and complicating risk factors such as advanced age or reduced kidney function. They then compared the calculated risk with the actually observed death rates. The difference between the prediction and reality allowed them to determine the quality of a transplant center.

It turned out that a greater proportion of blacks received their heart transplant at centers with higher-than-expected mortality as compared with whites and Hispanics (56.4% versus 47.1% versus 48.1%, respectively).

The contrast was even starker between the top- and worst-performing centers. Blacks had the lowest rate of being transplanted at centers with excellent performance (blacks: 18.5%; whites: 25.3%; Hispanics 28.3%). They also had the highest likelihood of undergoing their transplant surgery at the worst-performing centers.

It turns out that where a person has their transplant is critical. Only 8.7% of black patients died during the first year after the transplant if they were fortunate enough to undergo surgery at a top center. But this number was more than twice as high (18.3%) for blacks at the worst-performing centers.

The study didn’t provide any definitive explanations as to why the majority of blacks underwent heart transplantation at centers with lower than expected outcomes.

Choosing a transplant center isn’t much of a choice

Patients do not “choose” a transplant center by simply looking it up in a catalog or on a website. While performance statistics for each organ transplant center in the United States are publicly available in the Scientific Registry of Transplant Recipients, those statistics are only part of the decision for where a patient will get their transplant. The “choice” is often made for the patients by the doctors who refer them to a transplant center and by the accessibility of the center.

I’m a cardiologist, and in the Chicago area, where I practice, there are five active heart transplant centers. We can show the numbers for the centers to our patients when discussing the possibility of a heart transplant and also provide some additional advice based on our prior experiences with the respective transplant teams. Because our patients are nearly all based in the Chicagoland area, most of these programs are reasonable options for them. However, patients and doctors in cities or regions that don’t have as many transplant centers, or who live in more remote areas may not have the luxury of choice.

Accessibility matters because care doesn’t end with the surgery

Unless you’ve had a heart transplant, or know someone who has, it’s hard to understand just how life-changing the surgery is. I’ve noticed that many people are unprepared for the emotional and physical toll from the surgery and recovery. And it’s this toll that can makes accessibility such an important factor when choosing a transplant center.

After surgery, patients spend a couple of weeks recovering in the hospital. Even when they can go home, their health is closely monitored with frequent lab tests and check ups.

After transplant, patients will start taking medications to suppress their immune systems and keep their body from rejecting the new heart. And they have to stay on these medications for their rest of their lives. This means a lifetime of close monitoring to make sure that their heart is functioning well and that there aren’t any complications from the immune suppression.

For instance, during the first couple of months after surgery, patients have heart biopsies, where a small piece of the heart is removed to check for signs of rejection, every one to two weeks. As recovery progresses, biopsies may become monthly. The heart sample is so small that it does not damage the heart, but the biopsy is still an invasive procedure requiring hospitalization. And waiting for results can be stressful.

All of this means heart recipients spend a lot of time during the first year after their transplant seeing doctors and waiting for test results. Being close to a transplant center is important – it’s just easier to get to appointments. But accessibility isn’t just about the patient. It’s also about their support network. Imagine going through all of that alone.

On a practical level, family members and friends provide rides to the hospital, keep track of medications and doctor’s appointments and help with household chores during the recovery period. But what is most important is the emotional support that they provide.

So why do black transplant patients tend to wind up in transplant centers that don’t perform as well? Right now, we don’t know. Is it because they were referred to these centers by their cardiologists despite other feasible alternatives? What role does the health insurance of patients play in determining where they receive the heart transplant? Why are centers with a high percentage of black transplant recipients performing so poorly? And most importantly, what measures need to be taken to improve the quality of care?

These are important questions that physicians, public health officials and politicians need to ask themselves in order to address these disparities.

In the summer of 2010, over 20 million people were affected by the summer floods in Pakistan. Millions lost access to shelter and clean water, and became dependent on aid in the form of food, drinking water, tents, clothes and medical supplies in order to survive this humanitarian disaster. It is estimated that at least $1.5 billion to $2 billion were provided as aid by governments, NGOs, charity organizations and private individuals from all around the world, and helped contain the devastating impact on the people of Pakistan. These floods crippled a flailing country that continues to grapple with problems of widespread corruption, illiteracy and poverty.

In the summer of 2010, giant floods devastated parts of Pakistan, affecting more than 20 million people. The flooding started on 22 July in the province of Balochistan, next reaching Khyber Pakhtunkhwa and then flowing down to Punjab, the Pakistan ‘breadbasket’. The floods eventually reached Sindh, where planned evacuations by the government of Pakistan saved millions of people.

However, severe damage to habitat and infrastructure could not be avoided and, by 14 August, the World Bank estimated that crops worth US$ 1 billion had been destroyed, threatening to halve the country’s growth (Batty and Shah, 2010). The floods submerged some 7 million hectares (17 million acres) of Pakistan’s most fertile croplands – in a country where farming is key to the economy. The waters also killed more than 200,000 head of livestock and swept away large quantities of stored commodities that usually fed millions of people throughout the year.

The 2010 floods were among the worst that Pakistan has experienced in recent decades. Sadly, the country is prone to recurrent flooding which means that in any given year, Pakistani farmers hope and pray that the floods will not be as bad as those in 2010. It would be natural to assume that recurring flood disasters force Pakistani farmers to give up farming and migrate to the cities in order to make ends meet. But a recent study published in the journal Nature Climate Change by Valerie Mueller at the International Food Policy Research Institute has identified the actual driver of migration among rural Pakistanis: Heat.

Mueller and colleagues analyzed the migration and weather patterns in rural Pakistan from 1991-2012 and found that flooding had a modest to insignificant effect on migration whereas extreme heat was clearly associated with migration. The researchers found that bouts of heat wiped out a third of the income derived through farming! In Pakistan, the average monthly rural household income is 20,000 rupees (roughly $200), which is barely enough to feed a typical household consisting of 6 or 7 people. It is no wonder that when heat stress reduces crop yields and this low income drops by one third, farming becomes untenable and rural Pakistanis are forced to migrate and find alternate means to feed their family. Mueller and colleagues also identified the group that was most likely to migrate: rural farmers who did not own the land they were farming. Not owning the land makes them more mobile, but compared to the land-owners, these farmers are far more vulnerable in terms of economic stability and food security when a heat wave hits. Migration may be the last resort for their continued survival.

It is predicted that the frequency and intensity of heat waves will increase during the next century. Research studies have determined that global warming is the major cause of heat waves, and an important recent study by Diego Miralles and colleagues published in Nature Geoscience has identified a key mechanism which leads to the formation of “mega heat waves”. Dry soil and higher temperatures work as part of a vicious cycle, reinforcing each other. The researchers found that drying soil is a critical component.. During daytime, high temperatures dry out the soil. The dry soil traps the heat, thus creating layers of high temperatures even at night, when there is no sunlight. On the subsequent day, the new heat generated by sunlight is added on to the “trapped heat” by the dry soil, which creates an escalating feedback loop with progressively drying soil that becomes devastatingly effective at trapping heat. The result is a massive heat-wave which can wipe out crops, lead to water scarcity and also causes thousands of deaths.

The study by Mueller and colleagues provides important information on how climate change is having real-world effects on humans today. Climate change is a global problem, affecting humans all around the world, but its most severe and immediate impact will likely be borne by people in the developing world who are most vulnerable in terms of their food security. There is an obvious need to limit carbon emissions and thus curtail the progression of climate change. This necessary long-term approach to climate change has to be complemented by more immediate measures that help people cope with the detrimental effects of climate change by, for example, exploring ways to grow crops that are more heat resilient, and ensuring the food security of those who are acutely threatened by climate change.

As Mueller and colleagues point out, the floods in Pakistan have attracted significant international relief efforts whereas increasing temperatures and heat stress are not commonly perceived as existential threats, even though they can be just as devastating. Gradual increases in temperatures and heat waves are more insidious and less likely to be perceived as threats, whereas powerful images of floods destroying homes and personal narratives of flood survivors clearly identify floods as humanitarian disasters. The impacts of heat stress and climate change, on the other hand, are not so easily conveyed. Climate change is a complex scientific issue, relying on mathematical models and intrinsic uncertainties associated with these models. As climate change progresses, weather patterns will become even more erratic, thus making it even more challenging to offer specific predictions.

Climate change research and the translation of this research into pragmatic precautionary measures also face an uphill battle because of the powerful influence of the climate change denial lobby. Climate change deniers take advantage of the scientific complexity of climate change, and attempt to paralyze humankind in terms of climate change action by exaggerating the scientific uncertainties. In fact, there is a clear scientific consensus among climate scientists that human-caused climate change is very real and is already destroying lives and ecosystems around the world.

Helping farmers adapt to climate change will require more than financial aid. It is important to communicate the impact of climate change and offer specific advice for how farmers may have to change their traditional agricultural practices. A recent commentary in Nature by Tom Macmillan and Tim Benton highlighted the importance of engaging farmers in agricultural and climate change research. Macmillan and Benton pointed out that at least 10 million farmers have taken part in farmer field schools across Asia, Africa and Latin America since 1989 which have helped them gain knowledge and accordingly adapt their practices.

Pakistan will hopefully soon engage in a much-needed land reform in order to solve the social injustice and food insecurity that plagues the country. Five percent of large landholders in Pakistan own 64% of the total farmland, whereas 65% small farmers own only 15% of the land. About 67% of rural households own no land. Women own only 3% of the land despite sharing in 70% of agricultural activities! The land reform will be just a first step in rectifying social injustice in Pakistan. Involving Pakistani farmers – men and women alike – in research and education about innovative agricultural practices in the face of climate change will help ensure their long-term survival.